J HK Coll Radiol. 2009;11:183-185

CASE REPORT

Haglund Syndrome — a Characteristic Cause of Posterior Heel Pain EHY Hung,1 WK Kwok,2 MMP Tong1 1Department of Diagnostic Radiology and Organ Imaging, Prince of Wales Hospital, and 2Department of Radiology, North District Hospital, Hong Kong

Abstract This report is of a 48-year-old man with a painful swelling of the left heel, who was diagnosed with Haglund syndrome. The characteristic radiographical and magnetic resonance imaging features are described.

Key Words: Achilles tendon; ; Calcaneus; Magnetic resonance imaging;

Introduction Posterior heel pain is a common problem and has a variety of causes. Haglund syndrome is a characteristic cause of posterior heel pain, and consists of a con- stellation of and bone abnormalities. The condition is characterised by a prominent posterior bursal projection of the calcaneum, Achilles tendino- sis, and inflammation of the retrocalcaneal and retro- Achilles bursae.

Case Report A 48-year-old man presented in 2007 with left heel pain and deformity for 1 year. He had a history of a right above-knee amputation for haemangioma 20 years pre- viously, but was otherwise in good health. At physical examination, there was a tender swelling at the Achilles tendon insertion of the left heel. Simmonds test revealed an intact Achilles tendon.

Figure 1. Lateral radiograph of the hindfoot showing a prominent Lateral radiograph of the left ankle showed soft tissue bursal projection of calcaneum (black arrow), loss of lucency swelling at the insertion of the Achilles tendon, ossifica- in the retrocalcaneal recess suggesting tions within the thickened Achilles tendon suggesting (asterisk), ossifications in the thickened Achilles tendon (short arrows), and convex superficial soft tissue swelling at the insertion tendinosis, a prominent osseous protuberance at the of the Achilles tendon (curved arrow). bursal projection of the calcaneum, and an increase in density of the retrocalcaneal bursa suggesting bursitis. Magnetic resonance imaging (MRI) subsequently No cortical erosion was present (Figure 1). revealed hypertrophy of the calcaneum at the bursal projection, associated with marrow oedema. Increased Correspondence: Dr EHY Hung, Department of Diagnostic T2-weighted signal intensity in the thickened Achilles Radiology and Organ Imaging, Prince of Wales Hospital, 30-32 tendon and a thin rim of circumferential high signal Ngan Shing Street, Shatin, Hong Kong. intensity were indicative of Achilles tendonitis. Small Tel: (852) 2632 1247; Fax: (852) 2648 4122; dystrophic ossifications were present in the distal inser- E-mail: [email protected] tion of the Achilles tendon. Fluid in the retrocalcaneal Submitted: 23 September 2008; Accepted: 20 October 2008. and retro-Achilles bursae were compatible with bursitis

© 2009 Hong Kong College of Radiologists 183 Haglund Syndrome

(a) (b)

Figure 2. (a) Sagittal T2-weighted short tau inversion recovery; and (b) axial proton density images showing Achilles tendinosis with in- creased signal and ossifications at the insertion (short arrows), distension and increased signal of the retrocalcaneal bursa indicative of retrocalcaneal bursitis (asterisk), increased signal superficial to the Achilles tendon representing retro-Achilles bursitis (curved arrow), and bone marrow oedema of the protuberance of the bursal projection (long arrow).

(Figure 2). Overall, the features were compatible with of rest.7 Patients with Haglund syndrome range in age Haglund syndrome. from young adult to elderly, are of either sex although the condition is more common among women, and have The patient’s symptoms did not subside with conserva- varying patterns of daily activity.2 Hind-foot varus and tive treatment of analgesia and physiotherapy. The pes cavus are predisposing factors.5,6 Chronic stress patient underwent surgery, and the intraoperative find- is important to the aetiology. This patient would have ings of a large bony Haglund deformity, ossifications experienced increased stress to the left leg as the right within the thickened Achilles tendon, and retrocalcaneal leg had been amputated. bursitis were in agreement with the MRI findings. Lo- cal excision of the bony deformity and bursectomy of The condition is usually diagnosed by a combination of the retrocalcaneal bursa were performed. The patient’s clinical and radiological assessments. Plain radiograph symptoms markedly improved after surgery. in a lateral standing position is useful to assess the pres- ence of a prominent bursal projection of the calcaneum, Discussion the Haglund deformity. Different objective radiographic Haglund syndrome was first described by Patrick assessment methods, including the parallel pitch line and Haglund in 1927.1 This author established a connection posterior calcaneal angle or Fowler’s angle, are well de- between posterior heel pain, a visible and palpable soft scribed.2,3,5 However, these methods do not always agree tissue swelling, a pointed posterosuperior bursa border with the clinical symptoms.2,3 Assessment of the soft of the calcaneum, and the wearing of low back shoes.1 tissue detail is therefore crucial for making the diagnosis. Loss of a lucent retrocalcaneal recess is an important The condition is caused by mechanically induced in- indication of underlying retrocalcaneal bursitis.6,10 The flammation of the superficial bursa, Achilles tendinosis, Achilles tendon is swollen, and dystrophic calcifications retrocalcaneal bursitis due to repetitive compression may also be seen. Superficial bursitis usually manifests from the back of the shoes, and prominent bursal pro- as soft tissue swelling and convexity of the soft tissue jection of the calcaneum.2-9 posterior to the Achilles tendon insertion.

Haglund syndrome is characterised clinically by a pain- Although radiographic assessment is sufficient for the ful soft tissue swelling, the so-called ‘pump bump’, diagnosis for definitive cases, MRI may be required at the level of the Achilles tendon insertion. The pain for ambiguous or clinically equivocal cases. With its typically occurs when starting to walk after a period superior soft tissue and bone marrow signal contrasts,

184 J HK Coll Radiol. 2009;11:183-185 EHY Hung, WK Kwok, MMP Tong and multiplanar capability, MRI is more sensitive for assessment is useful for examination of the bony pro- making the diagnosis and assessing the severity of the tuberance, but MRI offers more sensitive and specific disease.10-14 The cardinal soft tissue abnormalities, namely assessment for making the diagnosis. Achilles tendinopathy, and retrocalcaneal and retro- Achilles bursitis, are more easily and directly depicted References by MRI imaging, with increased signal intensity demon- 1. Haglund P. Beitrag zur Klinik der Archillessehne. Zeitschr Orthop strated within the pump bump and Achilles tendon on Chir 1927;49:49-58. T2-weighted sagittal images.4,6,10 The detection of mar- 2. Pavlov H, Heneghan MA, Hersh A, Goldman AB, Vigorita V. The row oedema within the prominent bursal projection is Haglund syndrome: initial and differential diagnosis. Radiology. 1982;144:83-8. likely to support the repetitive mechanical compression 3. Burbenne LJ, Connell DG. Xeroradiography in the diagnosis of the and inflammation as the pathological mechanism in this Haglund syndrome. J Can Assoc Radiol. 1986;37:157-60. condition. 4. Kumar R, Matasar K, Stansberry S, et al. The calcaneus: normal and abnormal. Radiographics. 1991;11:415-40. 5. Stephens MM. Haglund’s deformity and retrocalcaneal bursitis. The differential diagnoses, including systemic inflam- Orthop Clin North Am. 1994;25:41-6. matory articular disorders such as Reiter syndrome and 6. Ly JQ, Bui-Mansfield LT. Pictorial essay: anatomy of and abnor- rheumatoid arthritis, are difficult to distinguish clinically. malities associated with Kager’s fat pad. AJR Am J Roentgenol. In contrast to Haglund syndrome, the pump bump associ- 2004;182:147-54. 7. Jerisch J, Schunck J, Sokkar SH. Endoscopic calcaneoplasty (ECP) ated with these inflammatory arthritic diseases are more as a surgical treatment of Haglund’s syndrome. Knee Surg Sports diffuse, and they are associated with cortical erosions of Traumatol Arthrosc. 2007;15:927-34. the bursal border of the calcaneum.2,3 Therefore, a careful 8. Steenstra F, Van Dijk CN. The Achilles tendon: endoscopic tech- search of any cortical erosion along the posterosuperior niques. London: Springer; 2007. p 133-40. 9. Sofka CM, Adler RS, Positano R, Pavlov H, Luchs JS. Haglund’s bursal surface of the calcaneum at MRI is important. syndrome: diagnosis and treatment using sonography. HSS J. 2006; 2:27-9. Treatment is often conservative to start, followed by 10. Narváez JA, Narváez J, Ortega R, Aguilera C, Sánchez A, Andía surgical bursectomy and resection of the Haglund de- E. Painful heel: MR imaging findings. Radiographics. 2000;20: 333-52. formity, either as open surgery or endoscopic surgery, if 11. Rosenberg ZS, Beltran J, Bencardino JT. From the RSNA Re- necessary.5,7,8,11 There is also a report of satisfactory pain fresher Courses. Radiological Society of North America. MR relief after local injection of steroid into the retrocalca- imaging of the ankle and foot. Radiographics. 2000;20 Spec neal bursa under ultrasound guidance.9 No:S153-79. 12. Robinson P, White LM. Soft tissue and osseous impingement syndromes of the ankle: role of imaging in diagnosis and manage- Posterior heel pain is a common problem, and there are ment. Radiographics. 2002;22:1457-71. various causes. Haglund syndrome has a characteristic 13. Bureau NJ, Cardinal E, Hoben R, Aubin B. Posterior ankle constellation of pathology, which consists of prominent impingement syndrome: MR imaging findings in seven patients. Radiology. 2000;215:497-503. posterior calcaneum projection, Achilles tendinosis, and 14. Kier R, McCarthy S, Dietz MJ, Rudicel S. MR appearance of retrocalcaneal and retro-Achilles bursitis. Radiographic painful conditions of the ankle. Radiographics. 1991;11:401-14.

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